Assessing the potential impact of Medicaid work requirements on African-Americans via a welfare reform analysis: A systematic review

The Centers for Medicare and Medicaid Services are currently approving Medicaid demonstration projects involving work and community engagement requirements. The fear among public health professionals and policymakers is that these work requirements will disproportionately limit access to health insurance for African-Americans. To investigate these new work requirements for Medicaid, we conducted a systematic review of the Temporary Assistance for Needy Families program, the last major welfare program to have such work requirements. We used the ProQuest database and selected scholarly journal studies in English and published between January 1991-August 2018. Our selection strategy yielded 14 eligible studies, eight of which focused on caseload movements and six focused on sanctions. We found that African-Americans entered TANF at a higher rate than Whites, remained on TANF longer, and were subject to sanctions more frequently and stringently than Whites were. These results suggest that African-Americans may disproportionately experience reduced access to care through sanctioning such as lockout periods. Recommended policy changes include prohibiting work activities as a condition of Medicaid coverage, strengthening Medicaid in other ways, combating discriminatory hiring practices, and easing burdensome reporting requirements.